|Year : 1981 | Volume
| Issue : 1 | Page : 13-17
A comparative evaluation of cyclocryotherapy, cyclodiathermy and cycloanemization in glaucoma
Manoj Shukla, Naresh Thakkur
Institute of Ophthalmology, J. N. Medical College, Aligarh Muslim University, Aligarh, India
Institute of Ophthalmology, J. N. Medical College, Aligarh Muslim University, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shukla M, Thakkur N. A comparative evaluation of cyclocryotherapy, cyclodiathermy and cycloanemization in glaucoma. Indian J Ophthalmol 1981;29:13-7
Various types of destructive procedures have been described in the management of severe intractable types of glaucoma. The fundamental basis of all these procedures is the selective and partial destruction of the ciliary epithelium. Vogt described the procedure of cyclodiathermy in the management of glaucoma. Since then many workers have described the therapeutic efficacy of this procedure in various types of glaucoma,,,. With the introduction of cyclocryotherapy by Bietti, a new era has opened in the management of severe and chronic types of glaucoma. This procedure has been further utilized and recommended in the treatment of various types of glaucoma by various workers'''. Streiff and Stucchi described a procedure of destruction of long posterior ciliary vessels in order to control increased intraocular pressure, which they termed cycloanemization. With this procedure they reported overall success rate of 57% to 64% in different types of glaucoma.
| Materials and methods|| |
64 eyes having fairly advanced, chronic and intractable glaucoma of various types [Table l], in which an open filtering surgery was not indicated because of some reasons, were subjected to different procedures aimed at selective destruction of ciliary epithelium. Majority of eyes were affected with absolute narrow angle or open angle glaucoma (40 eyes). Cyclocryotherapy was most common procedure employed to control the intraocular pressure in 26 eyes [Table - 2]. This procedure was used trans-conjunctivally using -50° to -60°C nitrous oxide cooled either as sectorial procedure or all-round applications i.e. 360° [Table - 3]. Cyclodiathermy was the second common procedure used either as surface cyclodiathermy (transscleral, 70-80 milliamperes for 7-8 seconds in 20 eyes) or perforating cyclodiathermy (transconjunctival, 40 milliamperes for 3-4 seconds in 12 eyes). Cycloanemization was tried in 6 eyes after detaching the insertion of lateral rectus following which diathermy applications were applied in three rows over bare sclera. The muscle was later stitched back to its normal anatomical position.
| Observations|| |
The overall results of various destructive procedures have been summarised in [Table - 4]. Following the initial application of these procedures, the intraocular pressure was controlled in 30 (46.86%) eyes. Out of these, the best results were obtained following cyclocryotherapy in 14 (46.67%) eyes, followed by the surface cyclodiathermy in 11 (36.67%) eyes. In the remaining 34 eyes the procedures had to be repeated second or third time, from periods varying from seven days to two months in order to control the intraocular pressure. Cycloanemization controlled intraocular pressure only in one eye out of six where this procedure was tried. In 5 eyes where this procedure failed cyclocryotherapy was undertaken, which controlled the intraocular pressure in these eyes following first application. As a whole the procedure of cyclocryotherapy controlled intraocular pressure in 27 (87.09%) out of 31 eyes where it was attempted followed, by surface cyclodiathermy (85%) and perforating cyclodiathermy (75%) as shown in [Table - 4]. Normotensive eyes were considered those where the intraocular pressure remained below 20 mm of Hg (Scbiotz) following these procedures. Intraocular pressure remained unresponsive in 10 (15.62%) eyes even after repeated applications. The various complications observed during the respective procedures are summarized in [Table - 5]. These complications were either seen alone or concurrently with one another. Except for the marked chemosis and swelling of the lids observed following cyclocryotherapy, no other major complication was observed with this procedure. This problem was basically seen in those eyes where an extensive cyclocryotherapy was undertaken and it gradually subsided. Iridocyclitis, hyphaema and vitreous haze were seen in few eyes. Follow up of few patients who were available for check up to one and a half years, revealed consistently good results in terms of control of intraocular pressure.
| Discussion|| |
The application of cyclodiathermy and cyclocryotherapy in the treatment of glaucoma has given a big boost to the management of certain severe and stubborn types of glaucoma Many workers have described the efficacy of these procedures in various types of glaucoma. Leydhecker and Polliot et al 3 described good results of cyclodiathermy in terms of control of intraocular pressure in 39% of eyes and 60% of cases respectively. De Roetth described extremely encouraging results of cyclocryotherapy in 57% of eyes having advanced chronic simple glaucoma. In the present study the best results of these destructive procedures were seen in congenital glaucoma followed by absolute primary glaucoma and advanced chronic congestive glaucoma [Table - 6]. The present study clearly shows that cyclocryotherapy is the best procedure in advanced intractable glaucoma of various types. Out of 26 eyes treated by this procedure intraocular tension was controlled in 14 (54.60%) eyes following first application, while in 8 (30.75%) eyes it was controlled following second or third applications [Table - 4]. 5 eyes where cycloanemization had failed, cyclocryotherapy yielded good results in terms of control of intraocular pressure. Thus following first application of cyclocryotherapy intraocular pressure was controlled in 19 (61.30%) out 31 eyes. As a whole the procedure of cyclocryotherapy controlled intraocular pressure in 27 (87.09%) out 31 eyes.
As is clear from [Table - 4], surface cyclodiathermy was the second best procedure which controlled intraocular pressure in 17 (85%) out of 20 eyes. However, this procedure is associated with danger of scleral thinning and necrosis. Perforating cyclodiathermy avoids this complication as it can be applied trans-conjunctivally. Further in the present investigation this procedure controlled intraocular pressure in 9 (75°x) out of 12 eyes. We therefore, feel that transconjunctival perforating cyclodiathermy is a better alternative to surface cyclodiathermy. This procedure has got a further advantage that repeated diathermy applications can be applied without making a conjunctival flap. Polliot et al have also reported very good long term results of perforating cyclodiathermy. Leydhecker however, feels that best results of cyclodiathermy are obtained following 160-260° diathermization. However, in the present study extensive diathermy was applied only in 5 out of 32 eyes [Table - 3], where diathermy procedure was undertaken. We therefore, feel that extensive diathermization of sclera is not justified when reasonably good results can be obtained with sectorial applications.
The efficacy of cycloanemization has been reported between 57-64%. However, in the present study intraocular pressure was controlled only in 1 (16.67%) out of 6 eyes, where this procedure was attempted.
Histopathological picture in human eyes after cyclocryotherapy has been reported by few workers,. Following this procedure both the pigmented and nonpigmented epithelial layers of the ciliary processes are separated from the adjacent stroma which shows oedema, vascular congestion and often haemorrhages. There is detachment and destruction of ciliary epithelium with replacement of ciliary processes by fibroblasts or scleral tissue. Late appearances show flat, irregular and matted ciliary processes which are displaced by fibroblast like cells. The trabecular tissue and the canal of Schlemm reveal vacuolization and fragmentation especially after prolonged treatment.
All these so called destructive procedures are fairly simple and are usually free from any serious complications. In view of their simple technique, good results and relatively less complications, such procedures should be considered as a routine wherever indicated. Specially in eyes with congenital glaucoma or advanced primary glaucoma, cyclocryotherapy seems to afford the best results out of all these procedures. We are in no position to categorically comment on the long term status of these procedures because of our inadequate follow up. Nevertheless patients who were available for follow up revealed consistently normal intraocular pressure.
| Summary|| |
64 eyes with advanced intractable glaucoma of various types were treated with various destructive procedures. Out of all, cyclocryotherapy gave best results. The postoperative complications noticed after these procedures are described. Long term follow up of eyes treated by these procedures is essential to exactly define the therapeutic status and efficacy of these procedures.
| References|| |
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[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]